Case Study On Lumbosacral Spine

On 8/15/16 I met Ms. Craton at the office of Dr. Tyler PCP. Ms. Craton arrived alone. She was able to sit and stand without difficulty. She is alert and oriented. Ms. Craton had a file folder with information for Hartford and Progress insurance. She is very cooperative agreeing to work with a nurse case manager and provide information.

MEDICAL FACTORS

Ms. Craton was driving on I-69 when a car weaving in and out of traffic caused a 4 car pileup. She reports she got out of her car and was standing at the side of the road. She bent over to pick up something and felt a pop in her back. She immediately went over to her PCP Dr. Tyler’s office. She was sent for an x-ray and a MRI of her lumbar spine. She tried physical therapy which increased her
pain. She is now awaiting a referral for epidural injections.

DIAGNOSIS/DIAGNOSTIC STUDIES/ SURGICAL INTERVENTIONS

Medical records provided by Dr. Tyler:
Lumbosacral spine x-ray done on 5/4/16: Compared to a prior film study done on 8/9/13.
Conclusion: stable mild degenerative change in the lower lumbar, no dynamic instability.

MRI of the Cervical spine done on 5/9/16: Comparison cervical spine MRI without contrast of 9/5/13. Conclusion: Stable appearance of the cervical spine with several small central disc protrusions with minor mass effect on the ventral cervical cord without cord signal change. No significant foraminal stenosis. Chronic maxillary and sphenoid sinusitis.

MRI of the lumbar spine done on 5/9/16: Conclusion: shallow broad base disc protrusion L4-5 without clearly evident abutment of the traversing right L5 nerve roots. Slightly eccentric to the right L5S1 disc protrusion possibly abuts the traversing right S1 nerve root. Low grade facet arthropathy.

CURRENT STATUS Ms. Craton reports she has low back, right buttocks and right leg pain. She also said she will have cervical pain and shooting down the right arm occasionally. She said she cannot sit for more than 30 minutes before she needs to get up and move around. She reports her sleep is also disrupted. She is unable to mow her lawn. She said her pain is a 7 and at night will increase to a 12. Ms. Craton lives with her fiancé who had a recent major heart attack. Ms. Craton said she was not able to tolerate physical
therapy.

CURRENT TREATMENT PLAN

On 8/15/16 I met Ms. Craton and Dr. Tyler. She has palpable pain to the low back. Dr. Tyler said she wants her to have an epidural injection to the S1 joints. If the pain decreases then she would have her restart the physical therapy program and then move to a core strength program. Dr. Tyler also wrote an order for a tens unit to see if that would help with her pain. Ms. Craton was instructed to follow up with Dr. Tyler 2 weeks after the epidural injection is done. No date for the injection has been obtained yet.

ADDITIONAL CONTACTS

Advanced Physical Therapy, 810-412-5100, I spoke with the location on 8/15/16 to confirm they have a tens unit training and will order her tens unit for her.

ATTENDING PHYSICIANS

Name: Dr. April Tyler (family physician)
Address: 1361 N. Long Lake Rd, Fenton, MI

Phone: [phone]
Last office visit: 8/15/16
Next office visit: 2 weeks after epidural injection

Name: Dr. John Morrison Nuclear Radiologist
Address: 3346 Lennon Rd. Flint, MI Phone: [phone]
Last office visit: no prior visit
Next office visit: appointment is pending

MEDICATIONS

Ms. Craton reported taking the following medications before the injury:
Birth Control
Sertraline 100 mg
Snythroid

Ms. Craton reported taking the following medications for this injury:
Vicoprofen 7.5 – 200 mg
Soma 350mg Ms. Craton said she is not allergic to any medications

DURABLE MEDICAL EQUIPMENT

Advanced Physical Therapy will order and train Ms. Craton with the tens unit.

ADL’S

Ms. Craton said she has needed help with her personal care, and house work. She reports she needs help with lawn work and has hired that to be done.

MEDICAL/SURGICAL HISTORY

Ms. Craton said her overall health before the accident was good. She denied any prior surgeries.

Ms. Craton denied smoking, only occasional alcohol use and denied drug use.

EDUCATIONAL HISTORY

Ms. Craton graduated from Davison High School. She has an Associates business degree from Mott College.

EMPLOYMENT HISTORY

1. Place of Employment: Right at Home Health Care
• Job Title: Senior service coordinator
• Start date: 2006 Stop date: current
• Hours per week: 40 +
• Job requirements and physical demands: Sits at a desk in front of computer.

CURRENT EMPLOYER CONTACT INFORMATION

Right at Home care has been updated of the current work status. Ms. Craton is off work until 9/14/16.

WORKERS’ COMPENSATION HISTORY

Ms. Craton denied any prior work injury.

FAMILY/SOCIAL/FINANCIAL FACTORS

Ms. Craton said she lives with her fiancé. She reports her home has 6 steps to enter, but once inside everything is on the main floor. She reports her fiancé had a recent massive heart attack and is unable to help with home maintenance.
Emergency Contact – Robert Bryan, my Fiancé, Phone is 810-620-5560

PHYSICAL DESCRIPTION

Height: 5 foot 6
Weight: 230
Hair: blond
Eyes: grey
Dominant hand: right

CLIENT’S FUTURE PLANS

Ms.
Craton said she wants to get better and get back to work.

CONSENT/EXPLANATION OF CASE MANAGEMENT

I explained my role as medical case manager and Ms. Craton verbalized understanding. She read and willingly signed the Authorization for Release of Medical Information form.

ATTORNEY

Ms. Craton denied any legal representation.

IMPRESSIONS

Ms. Craton is overweight and has a sedentary lifestyle. She reports that her overall health is good. She denied any prior lumbar or cervical issues but the Cervical spine MRI report showed a prior test in 2013. She is very motivated to return to work. The Official Disability Guidelines for Lumbar spine Intevertebral Disc Disorder with mylopathy is 63 to 227 days. Epidural injections are pending. I would expect additional physical therapy to be done. The length of disability for a Whip lash is 25 to 412 days. Her pain to the cervical spine is intermittent.

PLAN/ RECOMMENDATIONS 1. Contact Ms. Craton for updates on her medical status.
2. Attend appointment with Dr. Tyler 2 weeks after the epidural injection is done. Obtain an updated work status, treatment option and projections for MMI.
3. Attend appointment with Dr. Morrison Nuclear Medicine when made to obtain treatment
recommendations.